Transfers from LTPAC facilities to Acute care facilities. We answered some of the questions of the steps, and updated as follows:

  1. Referral to ED
    1. This is a notification, not a request. We will need to be careful to describe edge cases where ED cannot take the patient (re-routing, etc.)
    2. Starting set of the data needed from SNF to ED from Partners Healthcare
  2. Discharge from ED back to SNF
    1. Notification, with a summary of what happened in the ED - close the loop outcome
  3. Transfer to Hospital admission
    1. Notification from ED/Hospital to SNF
    2. Response from SNF to Hospital with additional information
    3. Can we keep the referral ID? Should we call it something else?
  4. Determination whether the patient will be discharged to the same SNF
    1. Can be due to timing - whether the patient bed can stay on hold for time necessary to be at the hospital - possibly a notification from SNF to hospital
    2. Patient may decide to look for a different facility - notification form hospital to SNF
  5. Patient Discharge - close the loop. Whether they go to the same SNF or another, follow the 360XL process of request, select, transfer
    1. Which identifier? Use two?

We need a diagram for this, any volunteers?

There are some existing transactions: - we will review in two weeks.

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